Diagnosis for P.T.

Diagnosis for P.T.

Hello, everyone.
I want to ask questions. Some of you might think the questions are so basic to them.
However, I'm asking because I'm not sure and want to get the correct answers to them.

Let's say, the patient has diagnosis of 1. Low back pain (724.2), 2. Cervicalgia (723.1), 3. Sciatica (724.3), 4. OA Knee (715.16)
In this case, in order to bill for PT treatment,
1. Is it reimbursible if I use the Low back pain as the primary pain?
2. Is 724.2 the correct code to use for low back pain?

It's all depends on the assessment or billing whether it is reimbursable or not..

As far as i know, let say, If you think 724.2 is really the primary diagnosis then you can use this as the primary diagnosis but be sure to read all the
assessment attached so that you can determine what is really the primary diagnosis, what is really the chief complaint of the patient and i think if you are
finished reading the assessment and you can tell what is really the primary diagnosis then use it as the primary DX (diagnosis) and it can be reimbursable if
you have complete assessment attached and of course correct codes of DX.

Thank you all for your replies.
To me, it seems like the patient's chief complaint is back pain in general.
Obviously, the patient complained about his low back pain, back pain, knee pain etc.
I thought it would be ok to bill low back pain (724.2) as patient's primary dx, but someone told me that it might not be reimbursed if I use that as the
patient's primary dx.

For purposes of occupational therapy services in this section,
carriers should substitute the words occupational therapy for each
occurrence of the words physical therapy".

Physician employees, under these guidelines, must meet all incident-to
requirements and general Medicare coverage requirements.

The following standards apply also to the practitioner services of
physician assistants, nurse practitioners, clinical nurse specialists,
and to persons providing services incident to practitioner services.

The following standards apply to physical therapy services provided by
a physician or by an incident-to employee of the physician in the
physician's office or the beneficiary's home. Medicare payment is based
on the Medicare physician fee schedule less coinsurance and any
deductible amounts due. For purposes of this instruction, physical
therapy services are those procedures found in the Physical Medicine
and Rehabilitation Section of the American Medical Association's
Current Procedural Terminology (CPT).

A. The services provided must be provided by, or under the
direct supervision of, a physician (a doctor of medicine or
osteopathy) who is legally authorized to practice physical
therapy services by the State in which he performs such function
or action. The patient must be under care of the physician for a
condition that is medically necessary, reasonable and
appropriate for physical therapy treatment. The services must be
considered under accepted standards of medical practice to be a
specific and effective treatment for the patient's condition.

B. The services must be of a level of complexity that require
that they be performed by or under the direct supervision of the
physician. Services which do not require the performance or
supervision of the physician are not considered reasonable or
necessary physical therapy services even if they are performed
or supervised by a physician.

C. Services must be furnished under a plan of treatment that
has been written and developed by the physician caring for the
patient. The plan must be established prior to the initiation of
treatment, must be signed by the physician, and must be
incorporated into the physician's permanent record for the
patient. The services provided must relate directly to the
written treatment regimen.

* When appropriate, the summary of treatment provided and
results achieved during previous periods of physical therapy
services.

2. The plan of care indicates anticipated goals and specifies
for the therapy services type, amount, frequency and duration.
The amount, frequency, and duration of the physical therapy
services must be reasonable and necessary.

3. The plan of care and results of treatment are reviewed every
30 days. When services are continued for more than 30 days,
the physician must recertify the plan of treatment every 30
days. Any change in treatment plan must be noted in writing in
the patient record.

D. The physical therapy services provided to the beneficiary
must be restorative or for the purpose of designing and teaching
a maintenance program for the patient to conduct at home. There
must be an expectation that the patient's condition will improve
significantly in a reasonable (and generally predictable) period
of time, or the services must be necessary for the establishment
of a safe and effective maintenance program required in
connection with a specific disease state. If the patient's
expected restoration potential would be insignificant in
relation to the extent and duration of physical therapy services
required to achieve such potential, the physical therapy would
not be considered reasonable and necessary. If at any point in
the treatment it is determined that improvement in the patient's
condition will not be achieved, the services will no longer be
considered reasonable and necessary.

E. Services that are palliative in nature are not considered
necessary and reasonable and are not covered services. These
services maintain function and generally do not involve complex
physical therapy procedures nor do they require physician
judgment and skill for safety and effectiveness.

Where there is an identified risk to the patient, the professional
skill of a physician may be required to manage and periodically
evaluate the appropriateness of a therapy maintenance program. When
the knowledge and judgment of the physician is necessary to prevent
or minimize deterioration caused by a medical condition, reasonable
management and evaluation services could be covered.

EXAMPLE: A Parkinson patient who has not been under restorative
physical therapy may require the services of a physician
to determine the type of exercises that will be
effective in maintaining the patient's present
functional level. Such a maintenance program, to be
covered under Medicare, must include the initial patient
evaluation, a maintenance program and care plan
appropriate to the capacity and tolerance of the
patient, and treatment objectives of the physician and
instruction of the patient or family members in carrying
out the program. Maintenance programs are subject to
such reevaluations may be considered reasonable and
necessary.